Emergency! (15 page)

W
hen you do CPR you get some blood flowing, but usually not enough to do more than keep the heart and brain alive for a few extra minutes. In rare cases, though, for reasons no one quite understands, you can actually provide almost normal blood flow just by pumping rhythmically on the chest.

We had such a patient once, a sixtyish man who was brought in by the paramedics in cardiac arrest. There were no family members, and we knew nothing about him.

His heart monitor showed ventricular fibrillation, which was a relatively good sign, since VFib is the only “rhythm of arrest” from which people really ever survive. Not that good, though, as only about 10 percent of people with VFib ever leave the hospital.

Shortly after he arrived, with CPR in progress, we were startled to see him open his eyes. With a breathing tube down his throat he couldn't talk, but he was clearly conscious. The CPR was keeping enough blood moving to his brain.

We checked the monitor just to be sure, but it really did still show VFib, and in fact, when we stopped CPR in order to do the check, the patient passed out again. Once we started up again, though, he rapidly responded and even seemed to make eye contact with the people above him.

CPR must be painful, but it's nothing compared to defibrillation, the big jolt of electrical energy we use for VFib. Ordinarily this doesn't seem relevant, since patients we shock like this are already comatose (if not, in some way, already dead). But this man was looking at us!

We had to do it, though, because VFib is not compatible with continued survival. And we didn't think it would be smart to give him any sedatives or pain medicines, because they all have suppressive effects on the heart. So we stopped CPR, and thankfully, while we were positioning the paddles, his eyes rolled back into his head and he went out before we shocked him.

Most patients respond to defibrillation by getting better (developing useful electrical activity) or getting worse (losing all electrical activity), but this man stayed the same, with VFib still on the monitor. We shocked him repeatedly, ultimately using the maximal current, and trying all our adjunctive drugs as well, but no matter what we did, his heart stayed in VFib.

And he stayed in the same extraordinary place not only between life and death, but between consciousness and death. Every time we did CPR, he opened his eyes and seemed to look into each of our eyes. And every time we stopped, even for a few seconds, he died.

With each shock the smell of his burned chest increased, and we were sure he was in agony each time he awoke. Although we usually call off our efforts if they've failed for a half hour or so (since when we succeed it's invariably in the first few minutes of CPR), we kept trying, and shocking, for two hours.

We had to keep going, because unlike so many patients in whom the sense of humanness is lost as they go through the act of dying, this man kept looking at us. He couldn't communicate or answer our questions, but the more we worked on him the more obvious it was that he was alert and even seemed to know that he was dying. And the more we worked on him, the more each one of us felt, as we acknowledged later, that he was looking right at “me,” that he was depending on each “me” among us to save him.

But none of our efforts worked, and over time it became more and more obvious that saving him just wasn't going to happen. If we changed positions so someone could get a breather from doing CPR, he died, and when we started up again, he was reborn! There was a temptation to stop on purpose for a few seconds, almost like a game, to witness this remarkable event. We also felt, with each successive
effort, an increasing dread of subjecting him to another defibrillation.

Finally, with the whole team exhausted, the ER backing up with other patients, and hope of success completely gone, we had to stop the resuscitation. We couldn't keep this up forever; it was futile, it was crazy. So we had to stop pumping on the chest of a man who was looking at us, knowing that when we did he would be dead. We could just stop, and he'd be dead soon enough. Or we could tell him.

One of the hardest things in medicine is telling a parent, or a spouse, or anyone, that someone he or she loves is dead. It's particularly hard in the ER, because you usually know neither the one who died nor the survivors. This was the first and only time, though, that I had to tell a patient himself. That I had to say, “We are going to stop trying, for reasons of our own, and you will die.” I didn't use those words, of course, but I couldn't keep from feeling that that was the underlying message, pure and simple.

I touched him, and said the most comforting things I could think of (even while someone else kept whaling on his chest so he could live through these eerie last moments). I tried to get him to communicate with me, to tell me if he wanted something, to forgive me, to curse me. Anything. But he didn't. He just kept looking at my eyes. Finally, I told him one more time, and then, a few seconds later, we stopped the CPR.

I've always wondered what he was thinking. Did he really understand what was going on? Was there something he wanted to say before it was over, or someone he wanted to say it to? Was he terrified that we'd stop, or terrified that we'd continue? Were his eyes begging me to keep him alive, or, please, just to let him die?

Twenty years later, I still think of him from time to time. And I still don't have a clue.

JEROME R. HOFFMAN, M.D.

Los Angeles, California
   

F
rom 1984 to 1991, I served as staff physician and medical director for the Yosemite Medical Clinic in Yosemite National Park. Although not a hospital, the clinic is the sole source of medical care for almost all of the twelve thousand square miles that make up Yosemite.

The summer is the busy season. I was on duty with one of my associates on a typical July day in 1988; we had only just begun and already there was a three-hour wait for nonemergency problems. We received a call on the radio that park medics were en route by helicopter from the Tenaya Lake campground with an unresponsive infant. CPR was in progress for the three-month-old female, who was not breathing and pulseless.

She was one of four children—the daughter her father had always wanted. She seemed fine that morning when she had been put down for a nap in the family tent while her parents made breakfast. They were only a few feet away and had been out of the tent less than five minutes when her mother returned to find her cold, pale, and lifeless.

The father was a well-established cardiologist with a group practice in Southern California. The mother was an ICU nurse. They immediately started CPR on their little girl while someone ran to call for assistance. The child was still apneic and pulseless as she was being loaded into the helicopter for transport. Flight time to our clinic was five to ten minutes. Flight time to a hospital of any size from Tenaya Lake was a minimum of thirty minutes.

We set up our one-bed ER with all that the clinic had available for
an infant resuscitation. One of the nurses came to me and said, “They're here,” and I vividly recall the gut-wrenching feeling I experienced knowing I was walking into a disaster. The child was mottled, cool, pulseless, and the monitor showed flatline. Intubation went smoothly, but we could not establish an IV. Dad arrived as I was working on a cutdown.

He was a large man—five to six inches taller than me and at least fifty pounds heavier. He could best be described as being in a state of controlled panic. When he realized that an IV had not been successfully established, he picked up equipment and made several attempts to start central venous lines himself. There was absolutely no way to persuade him to leave the room. We could not physically remove him—there was no one big enough to do so. After about twenty minutes, he finally gave in and joined his family in the waiting room. Resuscitation was terminated about forty-five minutes from the time of arrival.

The local priest had been called. After we stopped the resuscitation, I went out to look for the father. He was wandering around outside the building followed by the priest. My associate had gone back to start seeing other patients. Park medics had already been called away to another incident. I finally caught up to the father and he asked, “Is she gone?” When I said “Yes,” we hugged each other and cried together.

The following year, a woman in her late sixties was brought to the clinic in severe respiratory distress. She was initially attended to by a nurse and a respiratory therapist who were camping at the next campsite. The two followed the patient to the clinic to learn the outcome. I spoke to them and thanked them for their help. The nurse commented to her friend that she knew a cardiologist whose daughter had died in the clinic the year before. As it turned out, she was referring to the infant flown to us from Tenaya Lake.

I had not been in touch with the baby's parents during the year following her death. I got their address from the nurse and wrote to
the father. He soon wrote back saying he and his wife had had another child—a boy. The painful memories of the previous year so far prevented him and his family from returning to Yosemite; however, he hoped to be able to do so sometime in the future.

In my seven years in Yosemite, I participated in a total of six SIDS resuscitations. In five of those six cases, I felt that I was somehow able to maintain the balance of caring, compassion, and professionalism that comes with time. This case, however, was the worst and most devastating code in which I have ever been involved. The fact that the parents were physician and nurse—my colleagues, my professional family—seemed to drive the pain of this case much deeper. I still cry when I think about it.

GARY M. FLASHNER, M.D.
      

Wapwallopen, Pennsylvania

A
t 4
A.M.
the ER was finally quiet, except for the interrupted snores and snorts coming from room E, where the sole patient was dreaming drunken dreams after being “rescued” by emergency personnel from his pile of beer cans. Because in Utah the beer has only 3.2 percent alcohol content, it takes a case, drunken with swiftness and commitment, to get to the prized level of near-insensate stupor. I had to lean over a large yellow puddle to shake his shoulder. He grunted a somewhat underwater “Huh?” coughed once, then drifted back to his own, preferred world. Satisfied, I pulled up the blanket. The snore became muffled as I walked away.

“Here's a call from someone who wants to speak only with the doctor.” Katie was holding the phone like it was a dead snake. I reached for it and drew up a chair at the long white desk. I have never liked “advice” calls because they take the staff's time away from the patients. Especially at night they tend toward the macabre. This was no exception.

“Are you the doctor?” It was a whispering, feminine voice. “Is this totally confidential?”

“I can barely hear you. Yes, yes, go ahead.”

“I have to be quiet because my husband is in bed next to me sleeping.” The whisper held anxiety.

“I'm calling because my husband has AIDS and I just today got my test result back.” A pause. “It was positive.” Her voice choked, then became a monotone. “I don't know what to do.”

“Have you gotten any counseling?”

“Noooo.” Silence, then: “Also, I'm pregnant and I've started to bleed. I … I want to keep this baby.” She began to cry quietly.

“Why don't you come in and we can talk about it?” Suddenly I felt very alert.

“I can't. You see, I work at the hospital. I'm a medical student. If anyone found out about me being HIV positive, I'd be kicked out of school and never be able to get a residency or a job.… But I feel like I need to tell someone.”

“Have you told your husband any of this?”

“No.” A sob, interrupted by silence. “You know, he was promiscuous. He got AIDS from a friend. I came home one night, early. And there he was in bed with another man. He told me he could sleep with whoever he wanted. He wants me to engage in anal intercourse, but I won't because it's not right.”

“That's quite a burden you're carrying around with you. Why don't you come in tonight? No one else will know you've been here, just myself and the crisis worker.”

“I just want to feel better. I have twenty Percocets here. What would happen if I took them?”

“You know you'd hurt yourself. Are you threatening to hurt yourself?”
I was beginning to feel manipulated. This wasn't getting anywhere.

“I'm just asking you what I should do.”

“If you come in, I can help you. Otherwise, I can't.”

“You're not very understanding, Doctor. Sorry I bothered you.” With a click, her voice was gone. I looked at the white telephone in my hand, then placed it softly in its plastic cradle. I slid a new pen from the drawer, stared at it, and began to chart, wondering if I'd ever hear from her again. The next evening, while walking through the ER waiting room:

“Excuse me, are you the doctor?”

I knew it was the woman who had called. She had large, liquid eyes with brown pupils wide open, like a cat caught in the headlights of an onrushing car. Dark brown hair was pulled back, with a few tousled hairs meeting generous eyebrows. She wore pale green scrubs with trouser legs taped back in OR style. The V-top revealed two thin, gold chain necklaces which disappeared between the sides of two pale breasts. She wore a scrub gown loosely over her shoulders, like a shawl, only like a shawl designed by the Army. She pulled it tight over her chest with one hand, as if sensing a cool draft of night air. The movement revealed the curvature of her small breasts and flatness of her abdomen. She had the smooth skin of someone in her early twenties. Not a cat, I thought. She looked like nothing so much as a kitten waiting to be let in on a December night, tired and scared.

I suddenly wanted to put my arm around her.